Professional Documents
Culture Documents
6. Priapism
A painful persistent prolonged erection not related to sexual stimulation
Categories :
a. Low flow priapism most common, essentially due to haematological disease, malignant infiltration of
the corpora cavernosa with malignant disease, or drugs. Painful because ischemia of the erectile tissue
b. High flow priapism due to : perineal trauma, which creates an arteriovenous fistula. Painless
Diagnosis : obvious from the history and examination of the erect, tender penis ( in low flow priapism).
Characteristically the corpora cavernosa are rigis and the glans is flaccid. Examine the abdomen evidence of
malignancy, DRE to examine the prostate and anal tone
7. Back pain and Urological Symptoms
Occasionally patients with urological disease present with associated back pain.
2 broad categories of disease that may present with back pain and urological symptoms :
- Neurological conditions
- Malignancy of urological or non urological origin
8. Neurological Disease
Presentation : both back pain and disturbed lower urinary tract, disturbed bowel and disturbed
sexual function.
e.g : spinal cord and cauda equine tumors, HNP.
Back pain is the most common early presenting symptom gradual in onset and progress slowly.
Associated symptom : pins and needles in the hands or feet, weakness in the arm or legs, urinary
symptoms : hesitancy, poor urinary flow, constipation, loss of erection, loss of sensation of orgasm
or absent ejaculation, urinary retention.
9. Malignant Disease
Malignant tumours metastasize to the vertebral column
compress the spinal cord or nerve roots comprise the cauda equine.
The pain of the vertebral metastases may be localized to the area of the
involved vertebra but may also involve adjacent spinal nerve roots,
causing radicular pain
LOWER URINARY TRACT
EMERGENCIES
1. Acute Urinary Retention
Painful inability to void, with relief of pain following drainage of the bladder by catheterization.
Initial urine volume :
- < 500 ml should lead one to question the diagnosis
- 500 800 ml typical
- > 800 ml acute on chronic retention
Pathophysiology :
- Increased urethral resistance : BOO
- Low bladder pressure : impaired bladder contractility
- Interruption of sensory or motor innervation of the bladder
a. Causes in Men
- BPE due to BPH leading to BOO
- Malignant enlargement of the prostate
- Urethral stricture
- Prostatic abcess
It could be spontaneous or precipitated by an event.
- Precipitated retention : anaesthetics and other drugs ( anticholinergics, sympathomimetic agents e.g :
ephedrine), non prostatic abdominal or perineal surgery, immobility following surgical procedures, e.g : Total
Hip Replacement.
- Spontaneous retention : recur after TWOC require definitive treatment, e.g : TURP
Pediatric Female
Sistitis/post operative Cystitis/post operative
Overdistension Extrinsic Compression
Congenital Obstruction ( constipation/ovarial cyst/
gynaecological tumour/ uterine
( post uretral valve/urethral polip / prolaps/ hymen
hydrometrocolpos ) imperforata+hematocolpos/ skenes
Acquired Obstruction ( Blood gland abcess )
clot/post surgical obstruction ) Intrinsic Obstruction ( meatal
Neurogenic bladder stenosis/ urethral carcinoma/
urethral diverticula/ caruncula/
Trauma/abses ( app-perianal ) Fowlers syndrome )
Tumour ( sarcoma btoryoides ) Neurogenic ( DM/ spinal
hipermagnesia compression )
Psikogenic-histeria
Risk Factors for Postoperative Retention
Precipitated by : instrumentation of the lower urinary tract, surgery to the perineum or anorectum,
gynaecological surgery, bladder overdistention, reduced sensation of bladder fullness, preexisting prostatic
obstruction, epidural anaesthesia
Initial Management :
Urethral catheterization if failed : suprapubic catheterization.
Record the volume drained :
- < 800 ml acute retention
- > 800 ml acute on chronic retention
When the patient have a high retention volume (> 1000 cc) :
- Serum creatinine
- Renal USG : hydronephrosis
Anticipate that a post obstructive diuresis is going occur
TRAUMATIC UROLOGICAL
EMERGENCIES
1. RENAL INJURIES
The kidneys retroperitoneal structures surrounded by perirenal fat,
posteriorly are situated the vertebral column, associated spinal muscles
and the lower ribs, and anteriorly the content of the abdomen relatively
protecyed from traumatic injuries.
1-5% of all trauma cases.
Kidneys most common injured genitourinary organ
Male : female = 3 : 1
Mechanisms and Cause
Mode of Injury :
- Blunt injuries : as a result of direct blow to the kidney or rapid acceleration
or rapid deceleration (or combination of two or all three)
- Penetrating injuries : stab or gunshoot
Classification System
The American Association for the Surgery of Trauma (AAST)
GRADE DESCRIPTION OF INJURY
1 Contusion or non-expanding subcapsular haematom
No laceration
b. Laboratory Findings
Suspect a renal injury and arrange renal imaging in trauma cases with :
Macroscopic haematuria
Penetrating chest, flank, abdominal wounds (knives, bullet)
Microscopic hematuria (>5 RBCs/hpf) or a dipstick haematuria in
ahypotensive patient ( systolic BP < 90 mmHg recorded at any time
since the injury)
Haematuria is not always present in cases of renal injury, nor does the
degree of haematuria correlate with the degree of renal injury.
In renal vascular injuries or ureter or pelvireteric junction avulsion
haematuria (-)
c. Imaging :
- Contrast-enhanced CT Scan gold standard
- IVU has been replaced by CT-scan
- One shoot IVU
- Renal USG in evaluation of renal injuries.
Renal US establish the presence of two kidneys, retroperitoneal
hematoms, and with Doppler can identify the presence of the blood
flow in the renal vessel, but cannot accurately identify parenchymal
tears, collecting system injuries or extravasation of urine until a later
stage
Intravenous Urography for Renal Imaging
If the patient should be transferred immediately to the operating
theatre without having a CT scan and retroperitoneal hematoma is
found, a single-shot IVU taken 10 minutes after contrast
administration (2 ml/kg of contrast). If the patient is hypotensive,
take the image at between 20 and 30 minutes.
Very useful in determining the presence of a normally functioning
contralateral kidney.
Management :
- Conservative
- Surgical
Blunt Renal Injuries Management ` guidelineEAU2010
Gr. 1 - 2 Retroperitoneal
Stable
Renal Imaging Haematom
Gr. 5
Gr. 3 - 4 Pulsatile/Expanding
Associated
Observation :
injuries Renal Exploration
bed rest, serial
requiring Abnormal IVU
Ht, Antibiotic
laparotomy
Penetrating Renal Injuries guidelineEAU2010
Penetrating
Stable Hemodinamic Unstabe Hemodinami
Abdominal Trauma
c/ Renal injuries
Retroperitoneal
Stable
Observation : Haematom
bed rest,
serial Ht, Gr. 5
Antibiotic Pulsatile/Expanding
Associated
injuries
requiring Renal Exploration
Abnormal IVU
laparotomy
Follow Up
2. URETERAL TRAUMA
Relatively rare
1-2.5% of urinary tract trauma
Iatrogenic trauma commonest cause
It is seen in open, laparascopic or endoscopic surgery and often
missed intraoperatively.
Clinical Diagnosis
- External ureteral trauma : accompanies by severe abdominal
and pelvic injuries.
- Penetrating trauma associated with vascular and intestinal
injury
- Blunt trauma damage to the pelvic bones and lumbosacral
spine injury.
- Haematuria poor indicator
- Sign of delayed diagnosis : flank pain, urinary incontinence,
vagina or drain leakage, haematuria, fever, uraemia, urinoma
Radiological Diagnosis
- Extravasation of contrast medium in CT scan hallmark sign
- Hyrdronephrosis, ascites, urinoma, or mild ureteral dilatation often
the only sign.
- If CT scan is not available retrograde or antegrade urography is the
gold standard
- IVU especially one shoot IVU unrealiable diagnosis, negative
results up to 60% of patients
Management
3. BLADDER TRAUMA
Diagnostic Evaluation
Haematuria : Cardinal Sign
Signs of External Intraperitoneal Bladder Trauma : extravasation of urine,
visible laceration, clear fluid in the surgical field, appearance of the bladder
catheter, blood and/or gas in the urine bag during laparaoscopy.
Signs of Internal Intraperitoneal Bladder trauma : cystoscopic identification
: fatty tissue, dark space between detrusor-muscle fibres, or the
visualization of bowel. Sign of major perforation : inability to distend the
bladder, low return of irrigation fluid, abdominal distention
IBT not recognized during surgery haematuria, abdominal pain,
abdominal distension, ileus, peritonitis, sepsis, urine leakage from the
wound, decreased urine output, increased serum creatinine
Symptoms of an intravesil foreign body : dysuria, recurrent UTI, frequency,
urgency, hematuria, perineal/ pelvic pain
Supplement Evaluation
- Cystography : plain and CT cystography
- Cystoscopy
- Excretory phase of CT or IVU
- Ultrasound
Ruptur Buli
kartiko.ppds1uro-jan2009
Statistik Klasifikasi Ruptur Buli
10% of all trauma patients Intraperitoneal ( 34 % )
manifest genitourinary Extraperitoneal ( 58 % )
involvement (Schneider 1993) Combined ( 8 % )
among abdominal injuries that
require surgical repair, 2% involve
the bladder (Carlin and Resnick Cedera terkait
1995) 85 % terkait dg trauma tumpul
( 15 % dg trauma tusuk )
Penyebab 89 % terkait dg fr. Pelvis (
sebaliknya hanya 5 10 % Fr
Trauma pelvis berakibat ruptur buli )
- Tumpul ( 67 86 % )
10 20 % bersama adanya ruptur
- Tusuk / Crush Injury ( 14 33 % ) uretra ( sebaliknya 15 30 %
Ruptur Spontan trauma uretra post terdapat
Iatrogenik ruptur buli )
- SC ( insisi MLSU : Pfanennstiel = 7 : 1 )
- Laparoskopi : 2 10 x konvensional
Mekanisme
Extraperitoneal : hampir pasti terkait adanya Fr. Pelvis
daya tarik akibat pergerakan fraktur ( shearing force ) shg pelvic ring
kehilangan efek proteksi buli robek pd titik insersi ligamentnya
Lacerasi akibat robekan fragmen fraktur ( < 40 % )
Bursting type
Intraperitoneal direct blow
Bursting type : sudden increase in pressure in a full bladder ruptur
Dome : dinding paling tipis saat buli penuh ( susunan serat otot yg lebar )
Laserasi oleh fragmen pd high fracture of pelvic ring ( 25 % )
Anak
Insiden ruptur intraperitoneal lebih tinggi
Sebab anatomi buli letak abdominal baru akan mencapai letak
pelvis pd saat pubertas
Klinis Imejing
Gross Hematuria ( 86 95 % ) Sistografi ( immediately unless
Microscopis 25 200 eri/lbp life-threatening )
20 /lbp 25 % missed
Akurasi 85 100%
Suprapubic Tenderness ( 62 % ) Standar 5 film pd retrogard-
Jejas / nyeri suprapubik sistografi
Distensi abdomen Pelvis AP plain
Pelvis AP + 100cc kontras
Gangguan Miksi / Tdk bisa Miksi Pelvis AP / Lat + 400cc
Extravasasi urin ke perineum, Pelvis AP post miksi
scrotum / dinding depan Pd anak
abdomen Instilasi kontras 60cc +
Durante laparoskopi 30cc/tahun s/d max 400cc
Banayak cairan jernih di lap.
Operasi
Gas pd urin bag
Manajemen
Extraperitoneal
Trauma tunggal : pasang kateter uretra 10 14 hari sistografi
ulang kateter aff / prolong
Dg Trauma uretra : sistostomi sistografi antegard / BUS
Open jika dinding buli terjepit fragmen fraktur atau ada fragment
fraktur intrabuli atau ada cedera pd bladder neck, prostat atau
rektum
Ada Laparotomi : sekaligus pro eksplorasi repair buli
Buka dome : Repair ruptur dari intravesica dg chromic 3.0 kontinu
Debridement buli secukupnya : Hematome pelvis jgn dimanipulasi
Evaluasi : bladder neck, ureter distal, prostat, rectum, vagina
Jika ada cedera pd organ diatas harus langsung direpair cegah mjd fistula,
abses pelvis, BNS, inkontinen
Pasang kateter No. 18 -22 selama 10 -14 hari k/p + pasang sistostomi
( preventif re-open jika kateter uretra tdk adekuat )
Manajemen
Intraperitoneal + Trauma Tusuk
Pro Open Eksplorasi + Repair Buli cito
Midline insisi : memudahkan evaluasi pd organ intra abdomen
Buka buli dg melebarkan insisi dari laserasi
Evaluasi : bladder neck, ureter distal, prostat, rectum, vagina
Pastikan urin keluar dari ke-2 ureter jet
Jika ada cedera pd organ diatas harus langsung direpair cegah mjd fistula,
abses pelvis, BNS, inkontinen
Jahit laserasi 2 lapis scr kontinu dg chromic 3.0 / serosa dg Dexon 3.0
Pasang kateter No. 22 selama 10 -14 hari k/p + pasang sistostomi (
preventif re-open jika kateter uretra tdk adekuat )
Rupture Uretra
Management of urolgical emergencies
Cp.7 : Lower Urinary tract trauma- Kiaran J OMalley and anthony R Mundy
Emergencies in Urology Hohenfellner
Cp. 15.9 : Urethral Trauma L Martinez-Pinieiro
EAU Guideline 2010 ed
kartiko.ppds1uro-jan2009
Ruptur Uretra Posterior
Uretroskopi +
Guide wire Striktur Sistostomi
No Striktur
Pendek Tipis Panjang Tebal
Follow Up
Sachse Uretroplasti
Manajemen Cedera Uretra pd Wanita
Hematuria / Darah pd
Introitus Vagina
sistostomi Uretra
Proksimal / Retropubik repair
Bladder neck
Delay repair
Trans-vagina
Uretra Distal
repair
Posterior Urethral Injuries
kartiko.ppds1uro-jan2009
Cedera / kegawatan Penis
Tumpul ( 80 % )
Fraktur Penis
Tajam / Penetrating
Amputasi
Human / animal Bites
Missil / Zipper injuries
Iskemia
Priapismus
Protese / Injeksi
Diabetik / HD kronik
Injury Severity Scale for the Penis
EAU guide line 2010 ed
Trauma perineal /
Failure of smooth muscle
sebab lain
contraction
Kerusakan arteri
Persisten Ereksi cavernosa
persisten
Dx : BGA + USG
Doppler Non Iskemik
Priapism
Konservatif dg
Resolusi
Es
persisten
Embolisasi fistula dg
- Autolog blood clot
- polyvinyl alkohol Resolusi
- N-butylcyanocyalate
Open Ligasi
persisten
arteri
Manajemen priapism rekuren ( stuttering )
pd umumnya resolusi spontan kadang perlu medikasi, dpt digunakan salah satu
dibawah ini :
Polymicrobial necrotizing
fasciitis of the perineum
and genitalia
Most common in oldermen
(peak incidence in the 5th
and 6th decades)
incidence of 1/7,500, and
accounting for only 1%2%
of urologic hospital
admissions
10% of cases occur in
females
Penyebab Fourniers
Anatomi relevan
The pelvic outlet can be divided into
anterior and posterior triangles by
drawing a line between the ischial
tuberosities with the symphysis pubis
and coccyx being the apices
Urogenital causes of Fourniers
gangrene lead to initial involvement
of the anterior triangle
Anorectal causes primarily involve the
posterior triangle
The five fascial planes that can be
affected are:
Colles fascia, Dartos fascia, Bucks
fascia, Scarpas fascia and Campers
fascia
anatomi relevan
Colles fascia
is the fascia of the anterior triangle of the perineum. Laterally it is
attached to the pubic rami and fascia lata, posteriorly it fuses with the
perineal membrane and perineal body, and anterosuperiorly it is
continuous with Scarpas fascia
It prevents the spread of infection in a posterior or lateral direction,
but provides no resistance to spread in an anterosuperior direction
towards the abdominal wall
The dartos fascia
is the continuation of Colles fascia over the scrotum and penis.
Bucks fascia
lies deep to the dartos fascia, covering the penile corpora. It fuses
distally with the corona ofthe glans and proximally with the suspensory
ligament and crura of the penis
anatomi relevan
Campers fascia
is the loose areolar fascial layer deep to the skin of the abdominal
wall, but superficial to Scarpas fascia. Together with Scarpas fascia it is
continuous with Colles fascia inferomedially.
Scarpas fascia
lies deep to Campers fascia, covering the muscles of the anterior
abdominal wall and thorax.
It terminates at the level of the clavicles.
The perineal membrane
lies deep to Colles fascia. It is triangular in shape and lies between the
pubic rami from the symphysis pubis to the ischial tuberosities.
It has a distinct posterior border, with the central perineal tendon in
the midline.
Colles fascia terminates in this posterior border.
anatomi relevan
The central perineal tendon (or perineal body)
lies between the anus and bulbar urethra.
It serves as an attachment for the various perineal muscles and helps to
maintain the integrity of the pelvic floor.
Via the internal and external fascial layers of the spermatic cord,
the perineal fascia is continuous with the retroperitoneal fascia
This is a potential path for the spread of infection from the perineum to
the perivesical and retroperitoneal areas, and vice versa
Spread of infection along the fascial planes will follow the path of
least resistance
Infection in the anterior perineal triangle will spread preferentially in an
anterosuperior direction along Scarpas fascia,
lateral spread will be limited by fusion of Colles fascia to the ischiopubic
rami,
Posterior spread to the anal region will be limited by the termination of
Colles fascia in the posterior edge of the perineal membrane
anatomi relevan
Infection from the perianal region may sometimes penetrate Colles
fascia, which is fenestrated at the level of the bulbocavernosusmuscle,
leading to spread of infection to the anterior triangle
Anterior triangle infection rarely spreads to the posterior triangle
it is possible for infection to spread from the posterior to the anterior
triangle and then to the anterior abdominal wall
Blood supply to the testis, bladder, and rectum
Originates directly from the aorta and not from the perineal
vasculature, and for this reason they are rarely affected in Fourniers
gangrene.
If the testes are affected, it may be from specific testicular pathology
such as epididymo-orchitis, or from a retroperitoneal infection
spreading along the spermatic fascia, causing thrombosis of the
testicular arteries.
Mikroba penyebab
Fourniers
Patofisiologi Fourniers : polymicroba
Intravaskuler koagulasi
Late Complication
Chordee, painful erections, and erectile dysfunction
Infertility as a result of burying the testes in thigh pouches (high
temperature)
Squamous cell carcinoma in the scar tissue
Contractures due to prolonged immobilization
Depression secondary to dysmorphic body changes
Loss of income and disruption of family life due to prolonged
hospitalization
Lymphodema of the legs secondary to pelvic debridement and
subsequent thrombophlebitis
Prognosis
mortality of Fourniers gangrene ranges from 0% to 70%, with an
average of 20%30%
Diagnotic Evaluation
TRAUMA
Causa : - iatrogenic trauma
- external trauma